Rural communities of color across the U.S. are finding new ways to get the health care they need

For many in Brownsville, Tennessee, a rural town in the eastern part of the state, Haywood Park Community Hospital was the closest hospital.

Some residents believe that’s what kept their loved ones alive. But others in this majority-black city said they drove to a hospital miles away or didn’t seek treatment at all. The facility was eventually closed in 2014 after patient numbers dropped.

“Despite my bad feelings or experiences in this environment,” said Alma Jean Thomas Carney, who described the hospital’s white staff as unwelcoming, “there are destitute people living in Haywood County who need to go to the nearest available facility.”

According to the Centers for Disease Control and Prevention, people in rural areas die more frequently than city dwellers from diseases such as heart disease, cancer and stroke. But over the past decade, hospitals have been closing in rural America across the country, leaving some of the 46 million people who live in these areas with fewer options to get the care they need when they need it.

Advocates, hospital and health center leaders, and rural residents say changing disparities in health outcomes and health care in rural America must start at the local level — especially in communities of color where trust in medicine may not exist.

This is already happening in Brownsville, where the hospital fully reopened in 2022; in North Carolina, where mobile after-hours clinics provide care to farmworkers who do not have permanent residency status; and in California, where community health workers in the Fresno area are going door-to-door to help Punjabi-Sikh immigrants who often work on farms or in meatpacking plants.

“We have learned that we have to go to the people. We have to go where they are. They will not come to us,” said Mandip Kaur, health director of the nonprofit Jakara Movement.

More than a third of the nation’s rural hospitals – about 700 – are at risk of closure due to “severe financial problems,” according to a July analysis by the Center for Healthcare Quality and Payment Reform. Harold Miller, president and CEO of the center, said a hospital closure can impact a rural community.

“If the hospital didn’t exist, there wouldn’t be any doctors there,” Miller said. “There’s no place to go and get lab tests other than that hospital. There might not be a nursing home or a place to get rehab or long-term care other than those hospitals.”

If a hospital stays open in a large rural region where few people live, the facility may not serve the number of patients it would need to operate profitably, says Arrianna Planey, who studies health policy and management at the University of North Carolina.

Brownsville officials tried to find a buyer for the hospital. The county eventually bought it. Braden Health, a private company, then took over the hospital under two conditions set by the county: It must be a full-service hospital with a 24-hour emergency department, and it must hire staff as soon as possible. Local officials say the hospital is just breaking even.

Tennessee is one of 10 states – many of them in the South – that have not expanded Medicaid. Michael Meit, director of the Center for Rural Health Research at East Tennessee State University, believes this would be an obvious solution to the problem of growing health inequalities in rural areas. More people would be insured, Meit says, and hospitals could make more money.

“They provide a lot of uncompensated health care,” he said of rural health systems in those states.

While Miller acknowledged that expanding Medicaid could be helpful, he argued that relying solely on it would “absolve private health insurers of responsibility.”

“In some cases, small hospitals lose more money to private insurance than to Medicaid, which is really remarkable,” he said, “but they get so little … from private health insurers.”

Low Medicaid reimbursements, along with staff shortages and declining birth rates, are playing a role in the closure of maternity units in rural areas. More than half of rural hospitals have eliminated maternity services, another recent analysis from the Center for Healthcare Quality and Payment Reform shows. This can lead to longer travel times and a higher risk of complications and death, and in the U.S., black mothers have the highest maternal mortality rate.

Alexis Ratliff, 29, had few obstetric care options when she was pregnant with her second child. There is no hospital in Rocky Mount, Virginia, and one about 40 minutes away closed in 2022. Ratliff, who is Black, instead drove to Salem — more than an hour away — for every prenatal appointment. She used all of her paid vacation days and had no paid maternity leave.

She did, however, have a doula. The doula is black and her services were covered by Medicaid—a benefit Virginia began offering in 2022.

“I really wanted someone else to help me advocate for myself, especially because death rates are higher for women of color. So I thought to myself, ‘Anything can happen,'” she said. “My family members have never had good experiences up here in these doctor’s offices, even for regular appointments.”

In the southern state, immigration status can make health care difficult. North Carolina is home to about 150,000 farmworkers and their family members. Many of them speak Spanish, do not have permanent residency status and are not eligible for Medicaid – so they must pay for clinics out of their own pockets or go without medical care.

Some organizations in the state offer mobile health clinics. Campbell University’s Community Care Clinic, in partnership with NC FIELD’s Sembrando Salud, conducted its first public outreach in 2017 and diagnosed 68 people with diabetes. Four of them had very high blood sugar levels, said Dr. Joseph Cacioppo, a clinic volunteer and chair of the Community and Global Health program at Campbell.

“Three of them were lucky; when we found them, there was little or no organ damage,” he said, adding that the fourth had kidney failure and liver damage “because he didn’t know he was diabetic for so many years.”

There’s something else communities should strive for, says Alana Knudson, director of the NORC Walsh Center for Rural Health Analysis: a positive attitude and perspective.

“It’s not all dystopia,” she said.

“I think we’re really trying to change that narrative because that’s the challenge: Who wants to come from an older, poorer, sicker area? It doesn’t matter if you’re from inner-city America or rural America,” Knudson said. “Labeling that kind of thing doesn’t bring out the best in people’s feelings of self.”

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Aallyah Wright of Capital B, Claudia Boyd Barrett of California Health Report, Emily Schabacker of Cardinal News and Claudia Rivera Cotto of Enlace Latino NC contributed to this report. This story is part of joint reporting led by the Institute for Nonprofit News’ Rural News Network – with support from the Walton Family Federation. CatchLight provided visual support.

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The Associated Press Health and Science section receives support from the Robert Wood Johnson Foundation. The AP is solely responsible for all content.